ABC | Volume 114, Nº5, May 2020

Arq Bras Cardiol. 2020; 114(5):943-987 Guidelines Brazilian Cardiovascular Rehabilitation Guideline – 2020 in which most sessions take place in the patient’s home under indirect supervision, can supplement or serve as an alternative to traditional programs in which training sessions are always carried out under direct supervision. As in previous documents on this topic published by the Brazilian Society of Cardiology, 6,28-31 this guideline will exclusively address interventions based on physical exercise. The strength (or grade) of recommendation will always be proportional to the level of evidence available, as explained below. 1.1. Strengths (Grades) of Recommendation • Grade I : there is conclusive evidence, or, failing that, a consensus that the procedure is safe and useful/effective; • Grade II : there is conflicting evidence and/or divergent opinions on the safety and utility/effectiveness of the procedure: – Grade IIA : weight of the evidence/opinion is in favor of the procedure. Most experts approve; – Grade IIB : safety and utility/effectiveness are less well established, with no predominance of opinions in favor. • Grade III : there is evidence and/or expert consensus that the procedure is not useful/effective and, in some cases, can even be harmful. 1.2. Levels of Evidence • Level A : data obtained frommultiple, large, concordant randomized studies and/or robust meta-analyses of randomized clinical studies; • Level B : data obtained from a less robust meta- analysis, based on a single randomized trial or on non‑randomized (observational) studies; • Level C : data obtained from consensus expert opinions. 2. Structure of a Cardiovascular Rehabilitation Program 2.1. Staffing and Individual Responsibilities The makeup of CVR teams must be adjusted to its objectives, target audience, and availability of human and material resources, taking into account regional characteristics, the modality of rehabilitation (direct or indirect supervision), and the site or setting (hospital, outpatient clinic, etc.). A multidisciplinary CVR team is usually composed of physicians, physical educators, physical therapists, and nurses, but may also include other professionals, such as dietitians, psychologists, and social workers. 31,32 2.1.1. Primary Physician CVR is an integral part of the optimized clinical treatment of patients with stable CVD. Thus, it is essential that the CVR team and the patient’s primary physician work in an integrated manner. When referring a patient for rehabilitation, primary clinicians must be aware of its indications and potential benefits and should carry out the necessary pre-exercise evaluation. As this integration will involve frequent progress reports, potential needs for adjustment of drug therapy, awareness of complications and intercurrent events, etc., it is very important that mechanisms be established to facilitate communication between the patient’s primary physician and the CVR team. 31 2.1.2. Lead Physician of Cardiovascular Rehabilitation Program The lead physician coordinates all medical activities. In Brazil, this role usually falls to the general coordinator of the CVR program. He or she must have in-depth subject knowledge of CVR and be trained to act in cardiovascular emergencies. 6,32-34 Some of the main activities of this position include: a) Perform pre - exercise evaluation, including cardiopulmonary exercise testing as needed, to provide inputs for the initial prescription of CVR training sessions. 31 b) Train the CVR team to identify high-risk situations and provide appropriate care in emergencies. c) Establish restrictions and set limits for the exercise prescription. d) Lead and interact with other teammembers, to optimize the quality and safety of exercise prescription. e) Schedule follow-up evaluations, always in coordination with the patient’s primary physician. 2.1.3. Other Health Care Workers Like physicians, the other members of the team, when carrying out their respective duties, must follow the program’s rules and guidelines as well as the formal recommendations of their respective professional associations. 31 2.1.4. Physical Therapists and Physical Educators Physical therapists and physical educators are directly involved in the prescription and supervision of physical exercise, within the targets and limits defined by the physician as a result of the pre-exercise evaluation and follow-ups. They must have specific knowledge of CVD and exercise physiology and training in basic life support, including the use of an automated external defibrillator. Such training must be periodically refreshed to ensure continued competence. In addition to their direct role during CVR sessions, these professionals can provide patient guidance and contribute to other lifestyle measures aimed at adopting healthy habits. 2.1.5. Nurses In a CVR program, nurses and other nursing professionals can assist in clinical evaluation and obtain and provide information on the patient’s medical status, including through contact with family members. Nurses can also be in charge of blood glucose measurements and blood pressure (BP) checks before and/or during exercise sessions. In case of complications or intercurrent events, nurses can provide direct care, assist the physician and administer medications. Nurses must, of course, also be trained in basic life support, including the use of an automated external defibrillator. 947